VascularDoc.net - Questions to Vasculardoc

I have a question about celiac artery blockage. I was diagnosed about six months ago with celiac artery blockage. They found a bruit and it seems that this is the cause of my stomach problems. They told me it is 70% blocked or narrowed when they did a Doppler study. My family doctor was not sure if it was due to narrowing or blockage but it is now to the point that I can feel my pulse up and down my body when I lay on my left side. I had a colonoscopy done in September which was okay. When I asked him how serious this was he told me that he didn't know that much about it but that there was very little I could do about it. In the meantime my symptoms keep getting more frightening as they are more noticeable to me. Isn't there something I could or should be doing, like taking baby aspirin or something? I am 53 years old, 5'3'' and weigh about 90 lbs. normally. It seems like there is not a lot of information on the net about this and the symptoms I am having are pretty scary although all tests on my heart have come back fine. Do you have any suggestions?

Vasculardoc Answer:

The important symptom if there is a blockage of blood flow through the celiac artery (into the stomach and liver) is pain in the abdomen after eating a meal. "Feeling your pulse" when lying down is actually not uncommon in thin people such as yourself and while it may create an uneasy feeling, it is usually nothing to be concerned about (unless the prominent pulse is caused by an aortic aneurysm..and this is very easy to determine with an ultrasound exam..which you have already had). It is rare for a person to have significant problems with blood flow to the stomach and intestines if the only problem is a blockage of blood flow through the celiac artery. The reason for this is that there are other arteries which also supply blood to these organs. The superior mesenteric artery is the other main source of blood to the stomach and intestines. I hope you have had a consultation with a specialist. If you have not, I recommend that you ask your primary care doctor to refer you to a certified vascular surgeon.

Question for Vasculardoc: what to do about a blood clot in the lungs?

My mother had a clot in the calf of her leg and now has been told that it may have traveled to her l ungs as there is scarring of her lungs. She can not take warfarin due to her stomach and ulcer c onditions and is on daily Clexane injections which have bruised her stomach all the way across and h ave caused lumps to form. Now when she gives herself the injection it causes her to bleed. Apart from the depression is causing all of us good advice is hard to come by as to the steps she should take from here. It is not in our family and she is 49 year old active grandmother who is struggling to fight it. She complains of shortness of breath and is unable to lie in bed. She also has a slow immune system to rely on. What does scarring of the lungs exactly mean? What options are there?

Vasculardoc answer:

If the clot that began in her leg veins has traveled to the blood vessels of her lungs (a
"pulmonary embolism"), your doctors may consider placement of a vena
caval filter to prevent a recurrence. You should ask them if this
would be an option. The Clexane injections are an appropriate therapy
during the acute stages of a leg vein clot.

With time, many clots in the blood vessels of the lungs will "lyse"
(dissolve) and when that happens, many patients will experience an
improvement in their "shortness of breath". I hope this happens for
your mother.

Question for Vasculardoc: is my phlebitis taking too long to heal?

I have phlebitis in my lower right leg. I have had it for a while but have been under a doctors care for it for almost three weeks now. I have been taking tons (about 9 a day) Motrin, have been applying heat packs twice a day, and have had my leg wrapped in an ace bandage for about a week and a half. My swelling and the warmness of my leg has gone down but I still have the lumps and the soreness of the phlebitis. I have two questions: should it be completely gone by now or does it take longer to heal completely? Also, should I still be taking the anti-inflammatory? I have taken about 75 motrin in about a week and a half and am getting worried that this is too much. Thanks - Sharon

Vasculardoc answer:

From your description, it sounds like you have "superficial phlebitis" (as compared with "deep vein thrombophlebitis"). If this is the case, the clinical course that you describe sounds typical. It is not uncommon, in my experience, for patients to have persistent "lumps and soreness" for as long a s 6 weeks (and sometimes longer). It is likely that you could decrease the amount of anti-inflammatory medications at this point but I suggest that you check with your treating physician. Best regards and good luck.

Question for Vasculardoc: should a stent be used after a failed bypass?

A 62 y.o. woman had a left subclavian to carotid bypass that has failed. My question is should a stent be put here to try and open this up?? Thank you for your answer.

Vasculardoc answer:

Without getting too technical I would say the following: A carotid-subclavian bypass connects the carotid artery (artery to the brain) with the subclavian artery (artery to the arm). Depending upon which artery is blocked and which one is the "donor" artery, will determine which way the blood flows. This bypass can be used to bypass a blocked arm artery or a blocked carotid artery. If the bypass has failed, it might be a consideration to try to use a stent to open up a subclavian artery blockage (arm artery) but this depends upon the angiographic findings. I would usually not recommed a stent if the artery that is blocked is the carotid artery.

Question for Vasculardoc: how do I find a good vascular surgeon?

Can you recommend a resource for finding a good vascular surgeon/doctor? I've looked through all the doctors within my insurance plans network and NONE are listed as vascular surgeons. I'm not sure where to look next. Thanks.

Vasculardoc answer:

Finding a vascular surgeon in one's managed care plan can be challenging. For example, when a relative of one of my staff members needed carotid surgery a few years ago, her managed care plan referred her to a surgeon who we discovered did not perform carotid surgery more than a couple of times a year. We insisted that she be transferred to my hospital and I took care of her. Had we not known, who knows what might have happened? A way to search for a vascular specialist would be to start at: www.vascularweb.org

There is a link to "find a vascular specialist". You can search by state.

Question: What is the recovery period after injection therapy?

1) What is the recovery period after injection treatment? I've heard there can be months of bruised coloring in the legs before they look better.

2) Also, how are hemorrhoids and varicose veins related?

Vasculardoc answer:

1) Injections of small varicose veins and spider veins should heal very well in about 6 weeks (in my experience). Endovenous laser closure of the greater saphenous vein typically heals sooner than that.

(2) Hemorrhoids and varicose veins are both vein conditions that can be painful. Thrombosis and inflammation of the vein can occur in both conditions. Varicose veins are treated by vascular surgeons while hemorrhoids are treated by a colorectal surgeon.

Question: what is the recovery time after stent placement in a leg artery?

I was told I have 90% blockage in my right leg and 70% blockage in my left leg. I am scheduled have stents inserted the end of the month, and that I will stay over night in the hospital. Can you give me an approximate time length for recovery after the stents have been placed?

Vasulardoc Answer:

Since I don't know the details of your particular case, I can't comment about your specific situation. However, I can say that I usually tell my "typical" patient that they should rest and "take it easy " for a week after the stent insertion and then resume all activites. Good luck, I hope all goes well for you.

Question: I have carotid artery disease, what kind of diet is best?

I have just found out that I have Carotid Artery Disease - can you please tell me what kind of a diet I should follow. I am taking a full size aspirin per day. Will taking Folate, V-B6 and V-B12 help? Does stress contribute to this disease? Will stress make it worse?

Vasculardoc answer:

You should be on a low fat, cholesterol-free diet. Moderate amounts of the vitamins that you mentioned are often considered to be helpful. For my patients who have documented carotid artery disease, I usually recommend a cholesterol reducing medication. This can only be done under the direction of your physician. In my opinion, stress is a contributor to the development and progression of atherosclerosis.

Question: should my elderly mother have bypass surgery?

My mother is 86 yrs. old with the following medical history:
Diabetes
Quadruple heart bypass in 1995
Stroke in 1995
Left leg amputation above the knee in 1995
Left breast mastectomy in 2002
Some dementia and much memory loss
Bulbous pemphagoid (autoimmune disease of blisters on the skin)

The wound care center where she has been going to treat recurring leg sores that heal (but very slowly) is recommending that she have leg bypass surgery since she has almost no blood flow to her leg. I am loathe to subject her to this since she will not really understand what is happening to her. Also the sores on her leg do heal eventually. I know there is the risk of another amputation if sores get infected but that has not happened in 10 years. Can you give me any advice?

Vasculardoc answer:

You are faced with a very difficult, but unfortunately all too common, situation with your mother who you obviously care for very deeply. In my experience, older folks who are already somewhat disoriented tend to get much worse when they are placed in an unfamiliar environment like a hospital. As such, I generally agree that it is best to avoid hospitalization and surgery insofar as it is possible and safe to do so. I would want to know just how compromised the circulation is in her leg so an opinion can be rendered as to how likely it is that the sores will or will not heal. If an arterial non-invasive blood flow study has not yet been performed, I would probably recommend that test if she were my patient so an assessment can be made with as much information as can safely be obtained.

Question: can numbness improve after revascularization?

My mother had a stent put in her leg several years ago and was fine. The symptoms (tiredness) returned and she had five stents put in at the end of May. She continued to experience tiredness and numbness and found that the main stent was already 85% blocked after one month. She was scheduled for aorta femoral bypass surgery but both legs became numb, her feet turned blue and she began to have cramps in her legs. Bypass surgery was scheduled for the next day. The surgery went well but her feet and legs were still numb after surgery. Two days after surgery some feeling came back but she says her legs feel like boards. Is this normal and is it possible for the feeling to return at this point? Her pulses and color are good.

Vasculardoc answer:

The best news is that you describe the pulses and color as being "good". I would take this to be a positive sign and it suggests to me that one could hope for further improvement in the return of sensation in her legs and feet. The degree to which numbness resolves after blood flow is restored is usually related (in my experience) to the duration of ischemia (poor circulation). The shorter the ischemic time, the more complete the resolution of numbness.

Question: "Lifeline Screening" test

I had a "lifeline screening" test for my carotid artery. The technician said I was to see my doctor immediately. Should I be concerned?

Vasculardoc answer:

A "screening" is just that.an abbreviated examination of your arteries (typically the carotid and leg arteries and a quick scan of the aorta to look for aortic aneurysms). I wholeheartedly approve and endorse these tests but if the screening uncovers any suggestion of a problem (no matter how "minor"), it is necessary to follow-up with a certified vascular surgeon. Screening is noninvasive, relatively inexpensive, and can be life or limb saving. In my opinion, it is a very useful test.

Question: what causes ankle veins to bleed?

What is the cause of veins in the ankle area popping? They will pop and bleed profusely before they are under control. My worry is that one will break in the night and won't be noticed before the loss of blood will be fatal. What kind of treatment is needed for this and is a vascular surgeon who I need to see?

Vasculardoc answer:

You do need to see a vascular surgeon. The ankle veins are under high pressure because of incompetent ("leaky") valves in the veins higher up in the leg. If this "incompetent valve" condition can be fixed by either laser treatment of the leg veins or by removal of the veins, this is often an appropriate treatment. Sometimes the skin overlying the ankle veins gets so thin that with even very minor trauma, the vein will "pop". You are correct, the bleeding can be very severe. It usually happens when a person is standing and often times patients report that the bleeding first happened to them when they were standing in the shower. The important thing is to lie down immediately and elevate the leg as high as you comfortably can to decrease the pressure within the veins. Direct pressure over the vein is also helpful. One should seek emergency treatment (have someone call 911). Sometimes in the emergency room, it is necessary to place a stitch in the vein to stop the bleeding. Sometimes the bleeding can take some time to stop because patients are taking aspirin, Coumadin or Plavix for some other condition. If bleeding from ankle veins has occurred once, it can happen again. I definitely recommend that patients who have had an episode of bleeding go to see a vascular surgeon as quickly as possible after the emergency situation has been dealt with.

Question: why don't the doctors fix a 70% carotid artery blockage?

My Brother is 58. He had the widow maker 2 yrs ago and fully recovered. He has since been under the care of a cardiologist and today found out the results of his angiogram. The left carotid artery is 100% blocked. The right carotid artery is 70% blocked. My question is, why did they tell my brother and his wife they won't do the procedure to clean out the 70% blocked artery? I am so upset. I don't want to lose him. I know what the outcome will be without the procedure...a stroke .right? My mom had TIA and lived till 90 yrs. My brother exercises daily. He does drink beer daily (about three) and doesn't smoke. Is there some medication to dissolve the blockage?

Vasculardoc answer:

Carotid artery surgery is a serious procedure that is undertaken when necessary and not before it is necessary. A 70% carotid artery stenosis (blockage) is usually considered to be in the "borderline" range. In some patients, surgery is recommended and in others "observation" is the recommended course. The treatment plan must be individualized for each patient. If it is decided that surgery is not the preferred course, I would recommend that he be carefully watched for signs of worsening (with regularly scheduled ultrasound examinations of the carotid arteries). In the meanwhile, what I advise my patients is that they must very carefully watch their diet, take statin medications to lower the cholesterol level as far as possible and try to engage in some form of mild exercise (I recommend daily walking). A good number of patients will "stabilize" on a regimen such as this and many do not progress to need carotid surgery.

Question: a burning feeling and numbness. Do I have PAD?

I have a history of one TIA which occurred when I was 73. I am now 77. It was successfully treated with blood thinner and finally an Amplatzer PFO to close an opening in my atrium. My blood pressure is now under control. However, even though I am being treated with METFORMIN, my blood sugar has risen to 6.7.

I have recently been experiencing both a burning feeling and numbness in my leg and groin areas of both legs. This occurs if I stand for a while or when I sit with my legs elevated. It feels like my legs have gone to sleep and is relieved by placing my legs down or short walks. I also have a tendency toward bursitis in both hips. Question? Could this be an indication that I'm experiencing loss of blood flow in my legs or "PAD"?

Vasculardoc answer:

There could be an arterial problem ("PAD") and this is easily determined by a vascular surgeon and a Doppler evaluation. One must also rule out some form of nerve compression due to, for example, "spinal stenosis" (this is examined by MRI evaluation of the lumbosacral spine). Also, in any patient with diabetes who experiences burning and numbness of the legs and feet, one must consider the possibility of diabetic neuropathy.

Question: what can I do for a large lumpy dialysis fistula?

My left arm has a fistula for more than 15 years. I was on hemodialysis for 8 years. My left forearm fistula is still working. The appearance however is that of an extremely large bumpy vein approximately 10 inches in length. I am not experiencing any discomfort. Is there a way to reduce this area safely for appearance. My (kidney) transplant was June 2001 and all is terrific.

Vascularoc answer:

The best way to deal with this, in my opinion, is to remove the fistula.

Question: is inflammation of my carotid artery causing neck pain?

I have had neck pain directly on my left carotid artery for 10 days. It was about a 7 of 10 pain level in the first three days and has subsided to a 2 of 10. I went to my PCP yesterday and he informed me I had an inflammation of my carotid artery. He said he sees about 4 cases a year and prescribed 800mg Motrin 4 times daily. He said it could have been caused by a virus but there was no sure way to tell what caused it. I asked if plaque could have caused it and he said no. My last cholesterol check was 5/06 and was 226 (Tri: 224; LDL: 130; HDL: 51). I had been on Lipitor but my PCP took me off of it as he said I was borderline and should try to control with diet and exercise.

Could you please tell me what may have caused this and if the prescribed treatment is correct? Also, are there any long term complications from this? Are there any precautions I may take to prevent future occurrences?

Vasculardoc Answer:

Pain in the carotid artery is unusual. It is generally accepted that carotid artery plaque does not cause pain. It is certainly possible that you have an inflammation of the carotid artery, but this is unusual. If you were my patient, I would suggest that you undergo an imaging study of the carotid artery. An ultrasound study of the carotid artery performed in an experienced, certified vascular laboratory is suggested as a first step. Other studies that can be useful include an MRA (magnetic resonance angiogram) or a CT angiogram. These are all non-invasive tests that can be very helpful in defining the nature of your problem. Best regards.

Question: what to do when a person on Coumadin gets a bruise?

I take care of C-5 C-6 quad, he is on coumadin for 2 blood clots to the lung that came from his leg. Today I just noticed a big round golfball size on his elbow. When arm is bent at the elbow it feels spongy when its straight it feels like just extra skin. What should I check for?

Vasculardoc Answer:

Whenever a person is on Coumadin and develops any kind of lump, one has to think of the possibility that there has been some bleeding as the cause of the lump.

Another possibility that comes to mind with a "golf ball sized " lump at the elbow is inflammation in the bursa. This is called olecranon bursitis. If that is the case, it is not usually serious.

I suggest that you speak with the doctor who is helping you manage the Coumadin level.

Question: is my neck pain from my carotid artery plaque?

I have a 70% narrowing in my carotid artery. I have stiffness and pain in the neck on the side of the narrowing. Should I have the plaque removed from my artery?

Vasculardoc Answer:

Neck pain is not caused by plaque in the carotid artery. There may be important reasons to remove the plaque (for example: if it is causing a critical degree of narrowing, stroke symptoms, TIA, etc) but pain is usually not considered a reason to have carotid surgery.

Question: How many carotid operations should a surgeon perform?

How many carotid endarterectomy operations per year should be performed by a vascular surgeon to have the proper amount of experience for that operation?

Vasculardoc Answer:

That is a very good question and clinical leaders struggle with this issue all the time. It has been difficult to choose an absolute number for establishing credentials to perform this operation. Data collected thus far seem to suggest (as expected) that the best results are obtained by surgeons who do the operation on a regular basis but the minimum number to establish proficiency is not clearly defined. In my own opinion, I think that a surgeon should be performing at least 20 carotid operations annually to maintain proficiency in this area...but this is only one person's opinion. Others might argue that a lesser number is sufficient. Perhaps the more important question is: can the surgeon produce his/her results for the past 100-200 cases to show outcomes after this operation.

Question: are blocked femoral arteries associated with blocked coronaries?

Hello. My Husband has had pain in his legs while walking for a couple of years now. The pain stops with rest. Recently he had a MRA that revealed a 13cm occlusion in the right superficial femoral artery (SFA), and a 60% localized stenosis of the mid left SFA. He has been referred to a Thoracic Surgeon with recommendations of a right femoral bypass and a balloon angioplasty in the lower left extremity. My husband is 55 years old and overweight, he has high and somewhat unstable blood pressure, high cholesterol, and a recent blood test indicated he was borderline diabetic. His father had two heart attacks (one fatal) and his mother has had two heart surgeries and now has a pacemaker. Over the past couple of years he has developed an involuntary head bob. From everything I have read all of these factors indicate he is a high risk for heart attack or stroke.

My concern is that there is a blockage other than just his legs, and the MRA of his lower extremity did not tell us the big picture. Will the Thoracic surgeon do additional testing automatically or do we need to request additional tests. What questions should I ask to ensure that the surgeon looks at the big picture?

Vasculardoc Answer:

The symptoms and the MRA results that you describe suggest that your husband has PAD (peripheral arterial disease). You are correct to be concerned about the possibility that your husband has coronary artery disease as well. He has some risk factors that raise this concern including his strong family history of cardiovascular disease, his weight condition, his blood tests indicating the possibility of "borderline" diabetes and his high blood pressure.

In my opinion, before a recommendation is made to proceed with a femoral artery bypass, an evaluation by a cardiologist is advisable.

Question: is DVT caused by cycling?

I have been told that riding a bicycle can cause clots, is riding a motorcycle OK? What is the best exercise to do? Thanks for your help.

Vasculardoc Answer:

I do not know of any reports of people developing DVT after "casual" cycling. I have read reports of competitive cyclists who have developed DVT after intense riding over many hours (or even days). These clots are usually thought to occur when a cyclist gets dehydrated. When we are dehydrated, our blood "thickens" and clots more easily. Sometimes when a cyclist develops a blood clot after a particularly strenuous ride, it is also in the setting of a flight home after a competition. This period of inactivity on a flight (sometimes called "Economy Class Syndrome") in the setting of dehydration after a cycling competition is thought to cause the DVT.

Question: Should I have a stent in my carotid?

I had surgery on my left side last year. My right side is completely closed. now my left side is closing up again it is 70% closed. My question is there is no stent on my left side so would they put a stent in there or put me on counimun sorry about the spelling or just leave it????????? Thank you.

Vasculardoc Answer:

I would follow this situation closely (ultrasound exams every three months). If the narrowing progresses to more than 80%, I would consider re-intervention with either a stent or repeat carotid surgery. The reason I would probably not go in at this time (if you were my patient) is that the narrowing may stop getting worse and, in fact, may improve somewhat during the next 6-12 months. The usual situation in cases such as yours (where the narrowing re-occurs within two years after surgery) is that you have "neointimal hyperplasia" rather than plaque re-accumulation. This is a kind of an exaggerated healing response.I liken it to a "thick scar" that some people get. It is usually a smooth narrowing and usually does not cause symptoms through embolization. Since the other side is completely closed however, you and your doctors obviously would want to try to prevent the left side from closing down as well. You need to remain in close contact with your surgeon.

Question: isn't phlebitis serious?

I developed a red line, about 6 inches long, in my right leg below the knee. It was painful and hot. My doctor told me I had "phlebitis" and had nothing to worry about. I thought phlebitis was very serious. Is my doctor wrong?

Vasculardoc Answer:

What you are describing sounds like what is called "superficial phlebitis." A red, hot, painful streak on the lower leg, without swelling of the calf, sounds like superficial phlebitis. If the diagnosis is correct, your doctor is correct. Superficial phlebitis rarely causes any serious problems. It can be painful, but since it almost never causes a pulmonary embolism, it is not a life-threatening (or limb-threatening) condition. Deep vein phlebitis (DVT) on the other hand, is a serious condition requiring treatment with anticoagulants (heparin, Lovenox, and Coumadin) for several months, at least. It can lead to pulmonary embolism. Unless superficial phlebitis extends up the leg, all the way to groin, and then in to the deep veins of the leg, it is usually a self-limited condition. This condition is treated "symptomatically" (i.e. warm soaks to the affected area, aspirin, and anti-inflammatory medications).

Question: my cholesterol level was normal - do I need medications?

I went for a "Lifeline screening test" and they found a 60% narrowing of my carotid artery. My doctor checked my cholesterol level and it was 155. He wants me to take Lipitor. Do I need to do this?

Vasculardoc Answer:

In my experience, the "statin" medications are highly effective in not only reducing the blood levels of cholesterol, but also in reducing the plaque that has accumulated in the carotid arteries. I have observed patients who have been treated with drugs like Lipitor, Zocor etc.) and this has actually led to a decrease in the amount of carotid artery plaque that is seen on ultrasound evaluation. I recommend to my patients that they take a cholesterol reducing drug if they have a significant accumulation of carotid artery plaque regardless of the cholesterol level in the blood.

Question: "damaged" valve in leg

I have been told by 2 doctors that I have a damaged valve in my right leg and one doctor said the blood is not flowing back to my heart and that this could cause leg ulcerations and that I needed to have the laser surgery to seal off the vein. I had to go to another doctor because of insurance reasons and he said there are worse cases than mine and people live with this all the time. He did agree that the valve was damaged and the blood was not flowing. I want to have something done because the varicose vein and spider veins are taking over my whole calf and started up my leg.

My question to you is, is it correct that if something is not done that ulcerations and dis-coloration of my ankle and lower leg can happen? And after the laser procedure can you get the injections to take away the spider veins?

Vasculardoc Answer:

When the valves in a major leg vein become "damaged" through either inflammation or trauma, the valves become "leaky" and allow blood to settle in the leg. This frequently causes leg swelling and if the situation worsens further, the leg may get discolored (brownish color, called "stasis pigmentation") and the skin may actually break down and "ulcerate" (called "stasis ulceration"). This so called "venous insufficiency" can be treated by either removing the vein or by closing it off using a laser, for example. Since each case is different, I can not say whether treatment of your particular situation is necessary and if it is necessary, whether a laser treatment or surgery should be done. This will have to be decided in consultation with your own doctors. Treatment is usually very effective however and yes, after the vein with the damaged valve is taken care of, the spider veins and smaller varicose veins can be treated with injections or by use of another kind of laser.

Question: Arm swelling

My problem is, I have a blood clot from my collar bone to two inches below my elbow my arm swells a lot when I prop it up. The swelling goes to my breast on that side, I go to a hospital in Georgia . I am on 10 to 11mg. Coumadin daily. I was on Lovenox injections (90 mg) for over a month. I have an appointment in Vascular Surgery in about a week (they have canceled this appt twice and I have been dealing with this problem for four months). I am very worried I feel like something else is happening to me I am very tired all the time and bad head aches. Is there anything else I can do for this swelling, it is not just a little swelling it swells up like a balloon

Vasculardoc Answer:

From the history as you described it, it seems to me that you have a blood clot in your axillary and brachial veins, which are the structures that drain blood from the arm. This so called "axillary vein thrombosis" is not uncommon and it can occur spontaneously or it can occur in patients who have had catheters placed in the veins draining the upper extremity. When it occurs spontaneously (without a catheter in the vein), it is sometimes called Paget-Schroetter syndrome. The treatment of this condition is somewhat controversial with some vascular specialists recommending thrombolysis, some recommending treatment with anticoagulants such as heparin, Lovenox, and Coumadin; some vascular specialists recommending both thrombolysis and anticoagulation and sometimes even removal of the first rib because of the thought that the rib is causing blockage of the blood flow through the vein. Having treated many patients over the past 30 years who have had this condition, it has been my experience that patients (over time) do quite well without surgery and, in fact, many patients do well with treatment simply with Lovenox and Coumadin (as you have been treated). It takes some time (6 to 12 months) but, in my experience, most patients improve and do well. The swelling can be significant at first and it can take some time to improve. If the swelling is caught early (first few days after it happens), I usually recommend treatment with thrombolysis followed by heparin and Coumadin. I usually treat patients for a minimum of six months with Coumadin. As I mentioned, I do not recommend first rib removal. In patients who are referred to me late in the process, thrombolytic therapy is usually no longer an option and treatment with Coumadin for six months is usually quite effective, although it can take longer for the arm to improve in such situations. It is important to note that most of the time, the clot in the vein does not move and usually patients recover from this condition quite well. You described being "tired all the time and having bad headaches." In my experience, sometimes patients have these complaints related to the Coumadin therapy. My recommendation obviously is that you follow up with your vascular specialist and keep in close contact with him/her since the Coumadin therapy needs to be monitored and regulated very carefully so that there are no complications associated with the use of this medication and so that you get the best possible functional outcome of your following this clot.

Question: "Angioseal"

In late May of 2006 I had a heart cath. An angioseal was placed in my right groin area. I was in emergency surgery within 5 days to have it removed as a flap of skin had been pushed down on its insertion, plus my body size was too small for the angioseal, and I had lost blood flow to the foot.

A piece of vein was used to patch the artery. It has healed now and almost all the numbness of the area is gone. I am still having some issues with the area. It will "ache" around the incision as if the muscle is sore, and if I use my foot to try and slide something heavy, such as a heavy box that is too heavy to lift, it really is uncomfortable.

What are your thoughts on this?

Vasculardoc Answer:

Most of the vascular surgeons that I know have had to deal with complications of the "closure devices" used to seal the femoral artery after cardiac catheterization. The devices are used to prevent bleeding from the artery in the groin after the catheter used for the heart study is removed from the leg artery. Infection, clotting of the femoral artery, and loss of blood flow to the foot have been seen and surgery can be required to correct these problems. If there is normal blood flow to your foot at this time after repair of the femoral artery and removal of the "angioseal," there is usually nothing much else to do, except to allow the passage of more time for healing of the muscles, nerves, and other tissues. Best of luck to you.

Question: what exactly is an endarterectomy?

I recently (3/07) had thromboendarterectomy surgery on my left carotid artery. When the bandages finally fell off I was shocked to find a ropey scar running from my left ear to the mid-left side of my collarbone. My surgeon initially told me he would make a small incision to insert a stent to open the artery, scrape the artery out, remove the stent and add a "patch" inside the artery. That does NOT appear (to me) to be what he did.

When I asked him why I had such a large scar, he said he had to cut my neck open to reach the artery and scrape it out, then he used dissolving stitches to close it, and the dissolving stitches were causing the ropey scar which would disappear in about 6 months. That does NOT sound like what he told me he would do initially.

What, exactly, IS a "thromboendarterectomy", which is what this doctor's bill to me says he did. I could not find same on the internet except as was related to lung or heart surgery - NOT vascular surgery.

Vasculardoc Answer:

A thromboendarterectomy means that the plaque buildup and clot lining the inside of the artery are removed by opening the artery and scraping out the diseased tissue. A thromboendarterectomy can be performed in any artery to relieve obstruction to blood flow caused by buildup of plaque. When it is performed in the carotid artery, it is done to prevent a stroke. It is a very excellent procedure, better by far in my opinion than balloon angioplasty and stent placement in the carotid artery, in terms of a low rate of complications like stroke and in terms of long-term durability of the repair. While it requires making an incision in the neck, this is the price paid to avoid a stroke. Most neck scars heal nicely over time and your surgeon is correct, in my opinion: some people do have a reaction to placement of the "dissolving" stitches and the scar may take some months to flatten out and fade. Good luck.

Question: 100% blocked carotid artery

I have been diagnosed with a 100 % blocked carotid artery close to the aorta. I am 53 years old former smoker and borderline type 2 diabetic. I am in good physical health otherwise. I have had recent blood work and it all came back within normal limits with the exception of my blood sugar (110). I work out with weights and ride a stationary bike 20 minutes a day. I eat a very healthy diet. My primary physician tells me that since it is totally blocked surgery is not indicated. Do you agree?

Vasculardoc Answer:

The answer unfortunately is usually "yes". Once the carotid artery is completely closed, it is usually not the correct thing to do to try to get it opened again. The risk of stroke with such operations is high. This is the reason that vascular specialists try to identify patients with carotid artery narrowing before the artery closes up completely.

Question: The Silver Hawk Procedure

What is your opinion on the Silver Hawk procedure. I know that it is fairly new.

I have PAD, a small blockage, I have already had a angioplasty but it is blocked again. Claudation in the calf, but not severe.

Vasculardoc Answer:

So far, I have not been impressed with the results of the Silver Hawk device. My advice to patients in whom claudication is "not severe" is usually the following: walk every day, lose weight, manage your cholesterol and diabetes as best as you can, and do not smoke! With this regimen, most will improve...or at least not get worse.

Question: Lump in the groin after carotid stenting

I had carotid stenting done a week ago. I was not put under since I have COPD and lungs are very bad. Today I noticed a hard lumpy feeling in my groin where they went in. What does this mean?

Vasculardoc Answer:

It is common to have a small lump in the groin (about the size of a large marble) after procedures performed through the femoral artery (the groin artery). The lump is usually quite hard and it takes about 6 weeks to eventually go away. If the lump is enlarging or painful, or you are having other symptoms (such as fever for example), you should discuss this with the doctor who did the procedure.

Question for Vasculardoc:

What can cause a mottling look to occur on forearms? I have noticed this for the past three months. I have been to a dermatologist who said it was hives and treated me with antihistamines. The mottling is more under the skin than raised and looks like photos of livedo reticularis. I have also seen an Immunologist who ordered blood work, CBC, rheumatic tests came back negative, including hepatic panel, etc., all of which came back normal. Also, lupus was ruled out with one of the lab tests. I have seen my family doctor who gave me a shot of dexamethosone/kenalog on Monday which helped considerably. The blotchy skin has cleared somewhat, but is not gone. I had some redness across my upper chest that reached to both shoulders and around my neck and now that is almost completely gone since the injection. My skin does not itch but is sore and clothing bothers me and irritates it.

I am wondering if this could be chronic hives. I am going to have allergy testing in two weeks. Does this sound like a vascular problem or trouble with circulation? I have been told it is not vasculitis, however, I do notice that the mottling in my forearms decreases when I raise my arms above my head.

Vasculardoc answer:

It does not sound like this is a vascular problem. The improvement with Dexamethasone treatment suggests to me that there is an immunologic (or allergic) component to this condition. I agree that allergy testing is appropriate as part of the evaluation.

Question for Vasculardoc:

I am a 55-year-old woman who underwent stenting of both iliac arteries two years ago and now I have pain in both legs when I walk. In addition, the left leg "falls asleep" when I lie down at night. I find that it is helpful if I sleep sitting in a chair with my leg down or if I get up and walk around my bedroom. I am not diabetic, but I smoke cigarettes. Please advise.

New York City

Vasculardoc answer:

To have needed stents in both iliac arteries three years ago suggests that there is significant PAD with build up of plaque in both iliac arteries. It is concerning that you have pain in your leg ("rest pain") when you lie down. This suggests that the compromise of the arterial circulation to your left leg is serious and requires attention in the near future. Although approximately 80% of iliac arteries that are treated with a stent remain open after two to three years, it is likely that your iliac artery blockages have returned and that another intervention will be necessary. I advise you to seek an opinion with a vascular surgeon as soon as possible and discontinue cigarette smoking immediately.

Question regarding discoloration of legs:

I have noticed that there is brown discoloration of my ankles on the inside of the leg. It is not painful, but the leg is becoming dark and occasionally itchy?

Vasculardoc answer:

Venous stasis pigmentation is caused by high pressure within the veins. Because of the high pressure within the veins of the leg, red blood cells leak out of the capillary beds. The brown discoloration is caused by breakdown products of hemoglobin which are picked up in the skin cells and create darkening of the skin. The treatment of this condition is to correct the underlying vein disorder. In the worst form, venous stasis pigmentation can progress to enough thickening and loss of elasticity of the skin that patients will develop ulcerations of the leg.

Question regarding iliac artery aneurysms:

What size Aneurysm in the iliac artery needs to be repaired?

Vasculardoc answer:

The guidelines for aortic aneurysm repair are better defined than those for iliac artery aneurysm repair. In my own practice, I recommend repair of an iliac artery if it is three times larger than the normal adjacent artery. For the usual 1.0-cm diameter iliac artery, this means that I would recommend repair if the aneurysmal segment of the artery was 3 cm in diameter or larger. As with most things, however, each case must be considered individually and a determination made after consultation with a vascular surgery specialist.

Question regarding forehead veins:

49 y/o male here, extremely healthy and active. I am determined to find an answer to removing/diminishing my forehead veins (temporal, bilat) I am bald and it becomes THE prominent feature of my face....a very grotesque one indeed. What is the answer?

Vasculardoc answer:

You must determine, in consultation with a vascular specialist, if the bulging structure in your forehead is due to enlarged veins or is due to enlarged temporal arteries. If the structures are arteries, they should not be removed. If they are veins, it is possible that something could be done to make them less prominent. The distinction between arteries and veins can be easily determined by a vascular specialist.

Question regarding carotid artery plaque:

Can plaque in the neck break free and go into the brain; if so, does the artery need to be cleaned by surgery or can it be corrected by medicines?

Vasculardoc answer:

The answer is yes. The plaque can break loose or clot can form on the surface of the plaque and the clot could break loose and go to the brain (a so called "embolus"). If the plaque gets very thick, it is more likely to fragment and break loose. The rationale for prescribing aspirin or Plavix is to prevent clot from forming on the surface of the plaque. The rationale for cholesterol-lowering drugs such as Zocor or Lipitor is to prevent the plaque from getting very thick. Once the plaque gets thick, however, the cholesterol-lowering drugs are usually not adequate treatment and for such patients, removal of the plaque is often suggested by a vascular specialist.

Question to Vasculardoc:

Topic: Pain in thigh after heart cath

I had a heart cath Sept 6, 2006 I am having severe pain in my right leg groin inner leg to knee. I don't have a blood clot. I am desperate for a diagnoses. I had a angioseal closure device and in my search for a diagnosis have found about 13 other women with same symptoms and all had angioseal.

What could this be? Where should I go for a diagnosis?

Tennessee

Vasculardoc answer:

Many times when a person has pain on the inner aspect of the thigh after a procedure on the groin, it is due to irritation of a nerve in that area called the saphenous nerve. This "saphenous neuralgia" is sometimes seen after incisions in the groin for surgery on the femoral artery and it can also be seen after cath procedures during which a needle and catheter are placed into the femoral artery. Inflammation in the area is thought to irritate the nerve and cause the symptoms of pain shooting down the thigh.

Patients can experience pain along the inner aspect of the thigh and it can also extend down to the inner aspect of the knee. The pain is often described as a "shooting pain" or an "electrical kind of pain". It can also be associated with numbness in the same area. Some patients have both numbness to the touch and shooting pains down the inner thigh.

The diagnosis is usually a "clinical diagnosis". That is to say, CT scan or an ultrasound test (for example) will not show irritation of the nerve. It is important to first rule out a problem with the artery (such as a pseudoaneurysm or an infection, for example) and vein (such as a blood clot, for example). You mentioned in your e-mail that you do not have a blood clot, so I assume you have been checked by a vascular surgeon. If you have not been seen by a vascular surgeon, I recommend that you do so.

The diagnosis of "saphenous neuralgia" is usually made by a vascular specialist after ruling out any other abnormalities of the artery and vein. Most of the time, the discomfort associated with "saphenous neuralgia" will eventually go away. It can take many months however. Sometimes, consultation with a neurologist is appropriate.

An occasional patient has pain that does not go away and they are still uncomfortable 6 months or more after the procedure. In such cases, injection of the area with local anesthetics and anti-inflammatory medications by a pain specialist can sometimes be of benefit.

Question to Vasculardoc:

Topic: Aortic aneurysm in an elderly patient

I have a mother who is 84 years old living in Jakarta , Indonesia . She is now in the hospital suffering from kidney malfunction and aneurysm. I am not sure how big is her blood vessel now. She just went thru dialysis for her kidney last night. And now , she is waiting for stent/ring to be implanted in her heart pending her recovery from dialysis.

In your opinion, statistically, what is a chance of success for an old person to be planted with this ring? Should I be worried about her surgery since I am far away from her and my family. Do you know any hospital or doctor in Jakarta who specialized performing this kind of surgery? Thank you for your kindly response.

Iowa .

Vasculardoc answer:

When any person diagnosed with an aneurysm also has kidney malfunction ("renal insufficiency") this is a serious matter. Your mother's age of 84 years is also a factor that raises the risks of aneurysm repair. If the aortic aneurysm is able to be repaired with a stent, this would be preferable because it is more easily tolerated by most people than is the traditional "open" surgical repair. During stent graft repair however, an x-ray contrast agent or "dye" is typically used while the stent is being inserted under radiographic visualization. This "dye" can often cause some kidney damage. In the average patient with normal kidneys, the dye is usually not a concern. In a patient with pre-existing kidney malfunction however, the dye can make the kidneys worse. If a person is on the "borderline" between possible kidney recovery and permanent dialysis, the dye may tip the balance and cause the need for permanent dialysis.

Your Mother's situation is complicated and will require close consultation with the physicians and surgeons who are caring for her. The size of the aneurysm is very important. If the aneurysm is not too large, one consideration might be to postpone aortic aneurysm repair at this time and see if the kidney function will improve. This kind of decision can only be made by the medical team caring for her after they carefully consider all of the issues including the size of the aortic aneurysm, the location of the aneurysm, the extent of her kidney problem, her overall cardiac situation, and her overall strength.

Question to Vasculardoc:

Topic: Recurrent narrowing of carotid artery after surgery

If you have the right side of the carotid artery closed and the left side that you had surgery just about 9 months ago is starting to close up 68% what can be done since you only have the left side?

How serious is this?

Vasculardoc answer:

There are four arteries that supply blood to the brain. The internal carotid arteries (left and right) in the front of the neck and the vertebral arteries (left and right) which are located in the back of the neck. From what you tell me in your e-mail, you have had a left carotid endarterectomy about 9 months ago presumably because plaque was accumulating in your left carotid artery and starting to close it down. You describe the right side as already being closed completely. I presume that you have been told that ultrasound examination after your left carotid artery surgery is now showing that the left side is starting to close down just nine months after the surgery.

When this occurs so soon after carotid surgery, it typically is not due to

re-accumulation of plaque but rather is usually due to what is called neo-intimal hyperplasia. You can think of this as a kind of exaggerated healing response (like a very thick scar). It is usually a smooth narrowing (unlike narrowing due to plaque accumulation which often is irregular and rough). Many times the narrowing caused by neo-intimal hyperplasia will reach a certain point and stop but sometimes it continues to get even more narrowed. It needs to be followed closely with ultrasound examinations on a regular basis (every few months would be my recommendation) and if it continues to get worse, a balloon angioplasty and possible stent in the carotid artery is sometimes recommended. You should be in regular contact with your vascular surgeon.

Question to Vasculardoc:

Topic: Lump on arm while on Coumadin therapy

I take care of c-5 c-6 quad, he is on coumadin for 2 blot clots to the lung that came from his leg. Today I just noticed a big round golfball size on his elbow. When arm is bent at the elbow it feels spongy when its straight it feels like just extra skin. What should I check for?

Vasculardoc answer:

Whenever a person is on Coumadin and develops any kind of lump, one has to think of the possibility that there has been some bleeding as the cause of the lump.

Another possibility that comes to mind with a "golf ball sized " lump at the elbow is inflammation in the bursa. This is called olecranon bursitis. If that is the case, it is not usually serious.

I suggest that you speak with the doctor who is helping you manage the Coumadin level.